Meniscal repair and transplantation: indications, techniques, rehabilitation, and clinical outcome

The purpose of this paper is to provide current knowledge regarding the indications, operative techniques, rehabilitation programs, and clinical outcomes of meniscus repair and transplantation procedures. Meniscus tears that occur in the periphery may be repaired using a variety of operative procedures with high success rates. Complex multiplanar tears that extend into the central one-third avascular zone can also be successfully repaired using a meticulous vertically divergent suture technique. The outcome of these repairs justifies preservation of meniscal tissue, especially in younger athletic individuals. Meniscal transplantation is a valid treatment option for patients who have undergone meniscectomy and have related tibiofemoral joint pain, or in whom articular cartilage deterioration in the meniscectomized compartment is present. Rehabilitation after these operations includes knee motion and quadriceps-strengthening exercises initiated the first day postoperatively. The initial goal is to prevent excessive weight bearing and joint compressive forces that could disrupt the healing meniscus repair or transplant. The protocol contains modifications according to the type of meniscal tear, if a concomitant procedure is done (such as a ligament reconstruction) or if noteworthy articular cartilage deterioration is present. Patients who have repairs of peripheral meniscus tears are generally progressed more rapidly than those who have repairs of tears extending in the central one-third region or those who undergo meniscal transplantation. The safety and effectiveness of the rehabilitation program has been demonstrated in several clinical studies. We recommend preservation of meniscal tissue, regardless of age, in active patients whenever possible.     

Meniscal repair: open and arthroscopic outside-in techniques

This article reviews the principles of meniscal function and healing and provides an overview of techniques for meniscal repair, including open and outside-in techniques.     

Meniscal reconstruction. Part I: indications, techniques, and graft considerations

Menisci are specialized structures capable of bearing loads, absorbing shock, stabilizing, and lubricating the knee joint. Increased knowledge of meniscal anatomy and function, as well as studies of chronic anterior cruciate ligament-deficient and -reconstructed knees, have indicated that loss of meniscal function is associated with progression of degenerative changes within the knee. Meniscal reconstruction has been developed to preserve those functions prior to the development of significant degenerative changes in patients who have undergone meniscectomy. Indications are still being defined. Meniscal reconstruction has been achieved by either arthroscopically assisted or open techniques. Anatomic placement and secure fixation of the graft are requirements to allow the optimal revascularization needed for successful incorporation of the graft. Part I of this review will discuss the anatomy and function of the meniscus, followed by the indications, techniques, and graft considerations for meniscal allograft reconstruction. In Part II, which will be published in the May 1999 issue, we will review the results, potential complications, and future directions of meniscal allograft reconstruction.     

Laparoscopic Nissen repair: indications,techniques and long-term benefits

Background The Nissen fundoplication or total 360° fundoplication is probably the most frequently used anti-reflux procedure throughout the world. With the advent of laparoscopic surgery the popularity among surgeons to perform a laparoscopic Nissen fundoplication has even increased.Aim The purpose of this paper is to provide an overview of the experience of laparoscopic Nissen fundoplication over the past 15 years.Method We performed an extensive review of the literature in order to ascertain the representative papers. In addition, available consensus papers, especially with regard to indication and technique, were assessed. Indication for a laparoscopic Nissen fundoplication should depend on documentation of the presence of disease as well as objective testing of the functional disorders and the complications. The technique of Nissen fundoplication is discussed controversially. Consensus exists with regard to floppiness of the wrap, necessary closure of the crurae and the use of a calibration method during the performance of the wrap.Results The laparoscopic technique creates a learning curve, which needs to be respected. Large prospective series in recent years have shown a complication rate between 5% and 10%, depending on the definition of the complication. In these last prospective series good and excellent results have been reported, of between 85% and 95%. Reflux recurrence is reported as between 1% and 8.5%, with a concomitant dysphagia rate of 0%–10%.Conclusions The Nissen fundoplication is currently performed throughout the world, most frequently in a minimally invasive technique. Several randomized trials that have been performed in the past years document that the Nissen fundoplication is an effective procedure for the treatment of pathological gastro-oesophageal reflux disease when a critical indication is used for well-defined patients.     

腹腔镜治疗腹壁切口疝的指征和手术操作要点

腹壁切口疝是发生于原腹部手术切口的疝,是腹部外科手术后常见的并发症,其发生率为2%～11%,伤口发生感染后切口疝发生率高达40%左右[1-2].腹部手术切口疝不能自愈,均需手术治疗.单纯直接缝合修补切口疝的复发率可高达50%左右,对巨大切口疝修补更是外科治疗的难点.采用人工补片进行无张力修补术后,虽然将切口疝复发率降低至10%左右,但由于手术创伤较大,切口相关并发症仍较多. 1993年,LeBlanc 等首先报道了腹腔镜切口疝修补术, 随着修补材料及专用腹腔镜手术器械的研发,为此技术的临床应用提供了更多选择,其并发症少、复发率低及微创的优点,得到外科界的高度重视,应用逐步广泛[3-4].目前大多国内外学者积极倡导切口疝应首选腹腔镜修补.     

Meniscal repair devices

Summary: Meniscal repair devices not requiring accessory incisions are attractive. Many factors contribute to their clinical effectiveness including their biomechanical characteristics. This study compared several new meniscal repair devices with standard meniscal suture techniques. Using a porcine model, axis-of-insertion loads were applied to various meniscal sutures and repair devices. A single device or stitch was placed in a created meniscal tear and a load applied. Both loads and modes of failure were recorded. The load-to-failure data show stratification into 4 distinct statistical groups. Group A, 113 N for a double vertical stitch; group B, 80 N for a single vertical stitch; group C, 57 N for the BioStinger, 56 N for a horizontal mattress stitch, and 50 N for the T-Fix stitch; and group D, 33 N for the Meniscus Arrow (inserted by hand or gun), 32 N for the Clearfix screw, 31 N for the SDsorb staple, 30 N for the Mitek meniscal repair system, and 27 N for the Biomet staple. The failure mechanism varied. Sutures broke away from the knot. The Meniscus Arrow and BioStinger pulled through the inner rim with the crossbar intact. The Clearfix screw failed by multiple mechanisms, whereas 1 leg of the SDsorb staple always pulled out of the outer rim. The Mitek device usually failed by pullout from the inner rim. The Biomet staple always broke at the crosshead or just below it. Although the surgeon should be aware of the material properties of the repair technique chosen for a meniscal repair, this information is only an indication of device performance and may not correlate with clinical healing results.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 6 (September), 2000: pp 613–618     

Meniscal injury and repair: clinical status

Repair or resection of meniscal injuries is one of the most common operative procedures in orthopedics today. A variety of techniques for reconstruction have been attempted and experts are still unsure which treatment of meniscal lesions is best. This article reviews different techniques of meniscal repair and some novel approaches that may be used for treatment of meniscal lesions in the coming years.     

Meniscal repair: Outcomes and clinical follow-up

A retrospective study of arthroscopic meniscal repair in 101 consecutive patients was conducted. Sixty-three patients constituted our study group. The arthroscopic technique used for meniscal repair was the inside-out method using malleable cannulas. Forty-five patients were available for clinical examination, with a mean follow-up of 27 months. Tegner and Lysholm scores were comparable to those previously reported for arthroscopic meniscal repair. The HSQ (similar to the SF-36) scores were equal to those from an age- and sex-matched normal population, indicating that individuals with repaired menisci do not have any residual negative effects on global health at mean 26.9 months' follow-up. The physical functioning subscale of the HSQ was found to be sensitive to patient perception of results. Complications included one case of restricted knee range of motion requiring arthroscopy and lysis of adhesions. Overall clinical results were 64% excellent, 27% good, and 9% failure. Age, sex, and length of the meniscal tear had no affect on clinical outcome.     

Percutaneous biopsies: indications and techniques

Breast inflammation is a difficult clinical problem as it can result from a variety of causes: specific or non-specific infectious mastitis, which may or may not be complicated, primary or secondary inflammatory mastitis or inflammatory cancer. The main objective of radiology is to eliminate an inflammatory cancer. Other objectives are to characterise an inflammatory condition (where the clinical context is valuable in guiding diagnosis but which often requires a micro- or macrobiopsy) or to obtain a microorganism in cases of complicated infectious mastitis (a diagnostic procedure but also comprising the first stage of treatment). Whether for bacteriological or histological purposes, percutaneous samples therefore play a large part in the diagnostic procedure, other than in the clinical context of pregnancy where mastitis is more easily diagnosed because of its frequency. The guidance method is usually ultrasound, and the needle chosen will depend on the radiological or ultrasound signal: puncture with an 18G needle will be used for a bacteriological sample, microbiopsy of a mass or lymph nodes, or macrobiopsy in the case of microcalcifications.     

Total mastectomy: indications and techniques

Total mastectomy is an effective operation for patients who are candidates for a prophylactic mastectomy. This operation removes a larger percentage of breast tissue than subcutaneous mastectomy. The cosmetic results of total mastectomy with immediate reconstruction compare favorably with those of subcutaneous mastectomy.     

Penis tumours: techniques and indications

Although penis epidermoid carcinoma is a relatively rare tumour, early identification and treatment are necessary to avoid mutilating and sometimes morbid surgery. Awareness of disease epidemiology is mandatory for preventing the evolution of an underlying tumour (absent or insufficient hygiene, congenital or acquired phimosis, preepitheliomathous lesions such as Bowen's disease). Conservative surgical or radio-therapeutic techniques may be considered, provided the lesion is superficial and with a diameter < 30 mm. In all other cases, penis amputation is necessary. Penis epidermoid carcinoma spreads by vascular and lymphatic diffusion. Dynamic scintigraphy for the identification of a sentinel node and screening of subclinical metastasis is currently under evaluation. In case of palpable inguinal adenopathy, inguinal lymphadenectomy should be proposed if technically performable. Although superficial lymphadenectomy is associated with a low morbidity rate (about 3% of mild complications) deep inguinal Lymphadenectomy is far more morbid and disabling. Compliance with pre- and post-operative measures, and total patient compliance are necessary to minimize as far as possible such morbidity.     

Meniscal repair and regeneration: Current strategies and future perspectives

The management of meniscal injuries remains difficult and challenging. Although several clinical options exist for the treatment of such injuries, complete regeneration of the damaged meniscus has proved difficult due to the limited healing capacity of the tissue. With the advancements in tissue engineering and cell-based technologies, new therapeutic options for patients with currently incurable meniscal lesions now potentially exist. This review will discuss basic anatomy, current repair techniques and treatment options for loss of meniscal integrity. Specifically, we focus on the possibility and feasibility of the latest tissue engineering approaches, including 3D printing technologies. Therefore, this discussion will facilitate a better understanding of the latest trends in meniscal repair and regeneration, and contribute to the future application of such clinical therapies for patients with meniscal injuries.     

Ankle arthrodesis: indications and techniques

Patients with ankle arthritis and deformity can experience severe pain and functional disability. Those patients who do not respond to nonoperative treatment modalities are candidates for ankle arthrodesis, provided pathologic changes in the subtalar region can be ruled out. Several techniques are available for performing the procedure; the most successful combine an open approach with compression and internal fixation. The foot must be positioned with regard to overall limb alignment and in the optimal position for function. A nonunion rate as high as 40% has been reported. Osteonecrosis of the talus and smoking are known risk factors for nonunion. When good surgical technique is used in carefully selected patients, ankle arthrodesis can be a reliable procedure for the relief of functionally disabling ankle arthritis, deformity, and pain.     

Staged urethroplasty: indications and techniques

There is still a place for staged urethroplasty. There are some indications for staged urethral reconstruction such as strictures associated with chronic inflammation, fistula, false passage, urethral stones, urethral diverticula, abscess, failed prior repair, complicated hypospadias, severe trauma, neurologic diseases, extensive BXO strictures and long strictures. Staging a urethroplasty should not be considered a step backwards rather instead we should learn from experience and realize there are some patients who are too complex to reconstruct in a single stage.     

Urethral advancement for distal hypospadias repair, indications, techniques and results

Urethral advancement is a less well known technique for the repair of distal hypospadias. We treated 37 patients with a median age of 3 years for coronal and subcoronal hypospadias, with excellent results.     

Meniscal repair using engineered tissue.

In this study, devitalized meniscal tissue pre-seeded with viable cultured chondrocytes was used to repair a bucket-handle incision in meniscal tissue transplanted to nude mice. Lamb knee menisci were devitalized by cyclic freezing and thawing. Chips measuring four by two by one-half millimeters were cut from this devitalized tissue to serve as scaffolds. These chips were then cultured either with or without viable allogeneic lamb chondrocytes. From the inner third of the devitalized meniscal tissue, rectangles were also cut approximately 8 x 6 mm. A 4 mm bucket-handle type incision was made in these blocks. The previously prepared chips either with (experimental group) or without viable chondrocytes (control group) were positioned into the incisions and secured with suture. Further control groups included blocks of devitalized menisci with incisions into which no chips were positioned and either closed with suture or left open with no suture. Specimens were transplanted to subcutaneous pouches of nude mice for 14 weeks. After 14 weeks, seven of eight experimental specimens (chips with viable chondrocytes) demonstrated bridging of the incision assessed by gross inspection and manual distraction. All the control groups were markedly different from the experimental group in that the incision remained grossly visible. Histological analysis was consistent with the differences apparent at the gross level. Only the experimental specimens (chips with viable chondrocytes) with gross bridging demonstrated obliteration of the interface between incision and scaffold. None of the control specimens revealed any cells or tissue filling the incision. Tissue engineering using scaffolds and viable cells may have an application in meniscal repair in vivo.     

Meniscal repair. An arthroscopic technique

Repair of a longitudinal peripheral meniscal tear permits salvage of this structure in a high percentage of cases. In previous reports an arthrotomy was used to accomplish this repair; in this paper an arthroscopic technique is presented. The potential risks are significant and include damage to the peroneal nerve and popliteal vascular structures, failure of meniscal healing and the usual complications of arthroscopy. The procedure is recommended only for the advanced arthroscopist who is advised first to establish clearly by cadaver dissections the anatomical relationships.     

Blood saving techniques: indications and contraindications

Pre- and peroperative blood saving can be realised in different ways, without inducing important changes in the biological parameters of the organism. Different replacement solutions are studied in detail. Three principal techniques are as follows: a) The peroperative autotransfusion consists in recovering the blood lost in the operative field during the surgical intervention, filtering it and transfusing it at the end of surgery. b) The peroperative normodilution consists in collecting a certain amount of blood (till up 2 l.) from the patients before operation; it is replaced by plasma expanders and transfused at the end of operation. c) The third technique, called the 'frog leap', consists in collecting blood during the weeks preceding surgery, in various amounts in function of the importance of the estimated blood loss. This blood is stored and transfused during intervention.